Client Insurance Information CLIENT INSURANCE INFORMATION FORMPatient Name*Phone Number*Patient's Date of Birth*Name of Primary Insurance Company*Name of Primary Member with the Specified Insurance Company*Primary Member's Date of Birth*Primary Plan or Policy No.*Primary Member ID or Certificate No.*Primary Group No. (for Alberta Blue Cross only)Patient Relation to Primary Plan MemberInsured MemberSpouseChildHandicapped DependentPart Time StudentFull Time StudentDomestic PartnerSelect if applicable:I have coverage with a Secondary Insurance Company.Name of Secondary Insurance CompanySecondary Plan or Policy No.Secondary Member ID or Certificate No.Patient Relation to Secondary Plan MemberInsured MemberSpouseChildHandicapped DependentPart Time StudentFull Time StudentDomestic PartnerBusiness Email*Please note, if insurance response is PENDING, we will follow instructions set out by your insurance company to void the claim and resubmit to be payable to the insured member. Hence, in such cases, we will collect the full visit amount up front and your insurer will pay you, the insured member, after. Please also note that we are unable to direct bill to your secondary insurance company. We ask that you pay your remaining balance up and submit your receipt to your secondary insurance company after. Finally, please note that services provided at our clinic are NOT eligible for Sun Life reimbursement.I accept these terms and conditionsSend
